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Presented By – Dr. Shivesh Mishra
July 29th , 2014
Department of Periodontics
I.T.S. Dental College, Hospital & Research CenterGreater Noida
Moderator- Dr. Shivjot ChhinaPerceptor-Dr. Saurav Kumar
Introduction to Aging General Effects of aging Effect of aging on peridontiumo Gingival epitheliumo Gingival connective tissueo Periodontal ligamento Cementumo Alveolar Boneo Bacterial plaqueo Immune response
Systemic diseases & Periodontal health Conclusion
The process of becoming older, a process that is genetically determined and environmentally modulated.1
It includes the complex interaction of biologic, psychologic, and sociologic process over time.
Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible." (Gorman, 2000)
The geriatric population has been growing fast over the last decades all over the world, changing demographics.
Changes in biochemical and physiological processes occur with aging in all body tissues, including the peridontium.
Human ageing induces histophysiological and clinical alterations in oral tissues.2
These alterations must be understood to differentiate pathological conditions from the altered physiology of oral tissues resulting from ageing .3
External
Hair Brittle, Less Abundant, Gray
Skin Dehydration, Decreased Elasticity, Thermo Sensitive
Eyes Diminished Vision, Enopthalmos
Nose Diminished Sense Of Smell
SecretoryGlands
Diminished Epithelial Activity
Internal
Renal Decreased renal blood flow Leading to waterretention, Difficulty in removing waste products
Vascular Rise in systolic blood pressure
GIT Constipation and gas accumulation due tohypotonic musculature
Gonads Decrease estrogen and androgen secretion
Liver Decrease hepatic function
Pancreas Decrease function (diabetes)
Alternations in oral motor functions
Lip posture Drooling, angular cheilosis
Muscles of mastication
Efficiency of Mastication decreases
Tongue Speech, dysphagia, traumatic bite injury
Swallowing Dysphagia
Taste Loss of sensation or decreased sensation
The tissues that support the teeth are called the periodontium, which consists of gingiva, periodontal ligament, cementum, and alveolar bone.
Anatomical and functional changes in periodontal tissues have been reported as being associated with the ageing process.4
Thining of epithelium & diminished keratinization.5
Increased epithelial permeability to pathogens
Decreased resistance to functional trauma.
Conflicting results have been reported regarding the shape of the retepegs.
A flattening of retepegs and an increase in the height of the epithelial ridges associated with ageing were both demonstrated.
Gingival sample obtained from a 25-year-old healthy subject. Normal aspect of epithelium layers, dermal papillae and connective tissue, without signs of proliferation (HE staining, ×10).
Gingival sample obtained from a 66-year-old subject. Thickening of epithelium due to acanthosis (HE staining, ×10).
Rom J Morphol Embryol 2013, 54(3 Suppl):811–815
In a morphological 3-dimensional study of the epithelium-connective tissue interface, connective tissue ridges were observed to be more prevalent in young individuals whereas connective tissue papillae were predominant in old individuals.
The change from ridges to papillae involves the formation of epithelial cross-ridges with advanced age.4
Number of cellular elements decreases as age increases.
The fibroblasts are the main cells in the synthesis of periodontal connective tissue.
In vivo and in vitro studies have shown functional and structural alterations in fibroblasts associated with ageing.6-8
Gingival fibroblasts (GF) may be constantly affected by oral bacteria and their products, such as the lipopolysaccharides(LPS), present in their cell walls.
The LPS induces GF to release some inflammatory cytokines such as prostaglandin E2 (PGE2), interleukin (IL)-1, and plasminogen activator (PA) 6, 14.
The influence of these inflammatory mediators on both GF and periodontal ligament fibroblasts (PLF) might account for the severity of periodontal disease.6
The effect of aging on location of junctional epithelium has been the subject of much speculation.
The apical migration of the junctional epithelium, with consequent gingival recession, has been discussed.
Although such a migration is associated with aging, the loss of insertion caused by aging alone may not seem to have clinical significance.9
Gingival recession progression may occur due to several factors, such as passive eruption caused by physiological wear of teeth, a consequence of anatomically thin tissues and toothbrushing trauma.
Apparently, gingival recession is not an avoidable physiological process caused by aging, but a cumulative and progressive effect from periodontal disease or trauma over time.5
Carranza’s clinical periodontology 10th edition Chapter -6 ,Page No. 94
Coarser and denser gingival connective tissue
Qualitative and quantitative changes to collagen
include;
◊ increased rate of conversion of soluble to insoluble
collagen.
◊ increased mechanical strength
◊ increased denaturing temperature
These results indicate increased collagen stabilization
caused by the changes in the macromolecular
conformation
There is also a reduction in the organic matrix production and in vascularization, and an increase in the number of elastic fibers.
Decreased number of fibroblasts
Decreased organic matrix production
Decreased epithelial cell rests
Decreased number of collagen fibers
↓
reduction or loss in tissue elasticity
Cells of PDL have reduced mitotic activity
Thickness of the periodontal ligament varies and may reduce due to the reduction in the force applied by masticatory muscles along the time in subjects with complete dentition or having dental elements with no antagonist.10
On the other hand, when several elements are missing, there might be an overload on the existing remaining teeth, with consequent periodontal ligament thickening.11
Increase in cemental width is a common finding.
Increase may be 5 to 10 times with increasing age.12
Increase in width is greater apically and lingually.13
Deposition takes place mainly in apical region to compensate for the physiological wear of teeth.
Reduction of bone mass.
More irregular periodontal surface of bone.
Less regular insertion of collagen fibers.
Increased bone resorption.
The reduction in bone formation might be due to a decrease in osteoblast-proliferating precursors or to decreased synthesis and secretion of essential bone matrix proteins.6
The extracellular matrix surrounding osteoblasts has been shown to play an important role in bone metabolism.
A possible dysfunction of this matrix might occur concomitantly with the ageing process.14
Oxygen-free radicals have been reported to cause cellular damage and, consequently, contribute to the ageing process.15,16
In an in vitro study, oxygen radical-treated fibronectin (FN) was found to inhibit bone nodule formation by osteoblastswhen compared to intact FN.
This finding suggested that intact FN plays an important role in osteoblast activity .
FN damaged by oxygen radicals during the ageing process might be related to less bone formation
Although age is a risk factor for the reduction of the bone mass in osteoporosis,it is not causative and therefore distinguished from physiologic aging process.
Age has been recognized as having much less effect in altering the host response
Difference between younger and older individuals can be demonstrated for T and B cells, cytokines,andnatural killer cells,but not polymorphonuclear cells and macrophages activity.
McArthur 17 concludes that “measurement of indicators of immune & inflammatory competency suggested that ,within the parametes tested ,there was no evidence for age related changes in host defences correlating with periodontitis in an elederly group of individuals ,with and without disease.”
NUTRIENT INCREASED
FUNCTION
DECREASED FUNCTION
VITAMIN A Bacterial adhesion
Salivary Antimicrobial
Properities,immunoglobulin And
Lymphocytes Production
VITAMIN E ----------------
--------------
Antibody Synthesis,response Of
Lymphocytes,phagocytic Action
VITAMIN C
----------------
--------------
Phagocytic Action Of Neutrophils
And Macrophages,antibody
Response
ZINC
----------------
---------------
Antibody Response,phagocytic
Function Of Macrophages
RIBOFLAVIN,VIT
B6,PANTHOTENIC ACID
--------------------
------------
Antibody
synthesis,cytotxic T-
cell toxicity,
lymphocyte response
FOLIC ACID AND
VITAMIN B 12
--------------------
------------
Cytotoxic T cell
toxicity,lymphocyte
production,phagocytic
function of neutrophils
IRON
--------------------
------------
Lymphocytic
proliferation,neutrophil
cytotoxic
activity,antibody
response
Loss of tooth substance – Attrition
Degree of attrition is influenced by
◦ Musculature
◦ Consistency of food
◦ Tooth hardness
◦ Occupational factors
◦ Habits like bruxism
◦ Continuous tooth eruption
Gingival recession
Dentogingival plaque accumulation increases with
increase in age:
• with Increase in hard tissue surface area resulting from
gingival recession
• The surface characteristics of the exposed root
surfaceas a substrate for plaque formation
For sub gingival plaque ,increased number of entric
rods and pseudomonads in older adults.
Periodontal pathogens specifically including an
increased role for P. gingivalis and decreased role for A. actinomycetemcomitans
Infectious diseases, such as periodontitis, cause inflammation and contribute to levels of overall infection and inflammation in the body and may trigger the beginning and/or the progression of other diseases such as diabetes and arteriosclerosis.18
There are two mechanisms through which infection and inflammation apparently located in periodontal pockets may harm general health:19
The passage of periodontal pathogens and their products into circulation (bacteremia)
The passage of locally produced inflammatory
mediators into circulation
JADA 2006;137(10 supplement):26S-31S.
It is suggested that the potential interactions between diabetes and periodontitis seem to enhance the morbidity of these two diseases.20
The chronic hyperglycemic condition of diabetes is associated with damage, dysfunction, or failure of various organs and tissues, including the periodontium.
It is due to the increased risk for infections in patients with diabetes, impairment of the synthesis of collagen and glycosaminoglycans by gingival fibroblasts, and increased crevicular fluid collagenolytic activity, Altered wound healing.21
It has been demonstrated by a meta-analysis study that patients with types 1 and 2 diabetes had worse oral hygiene and higher severity of gingival and periodontal diseases, compared to nondiabetic subjects.22
A multivariate risk analysis showed that subjects with type 2 diabetes had approximately threefold increased odds of having periodontitis compared with subjects without diabetes, after adjusting for confounding variables including age, sex and oral hygiene measures.23
Periodontal and cardiovascular diseases are common inflammatory conditions in the human population, atherosclerosis being the major component of the latter.
Loesche et al did a study on association between periodontal disease and coronary heart disease.
They found that in patients with periodntal diseases there are 1.84 times more CHD
Subgingival plaque flora
Increased access to flora (compared to supra gingival plaque)
Via ulcerated epithelial lining of the pocket
Underlying connective tissue
Antimicrobial potential in
tissues
Cellular debris
Systemic circulation
Alterations in serum components of clotting mechanisms
Elevated levels of fibrinogen
Risk of future coronary heart disease
Destroyed
A meta-analysis study indicated that individuals with periodontitis had 1.14 times higher risk of developing coronary heart disease.24
The more severe the periodontal disease the easier the periodontal pathogens could enter the circulation, reaching blood vessels and atherosclerotic lesions.
Another linkage between periodontal disease and CHD is the level of C-reactive protein, which is an acute-phase reactant in response to infection or trauma and its high sustained level was associated with advanced periodontitis.25
Ridker et al. demonstrated that C-reactive protein levels predict the risk of coronary events.26
Goal of periodontal treatment is to preserve function and prevent the progression of inflammatory disease
- Factors must be considered in treatment planningPatients
- Medical and health status - Medications - Life style behaviors- Ability to perform oral hygiene procedures - Ability to tolerate treatment - Amount of remaining periodontal support, tooth type
Operator side
- Decrease the length of surgical time - Maintain open communication - Minimize trauma- Recalculate medication dosages- Schedule morning appointment
- Non surgical approach – first treatment of choice
- Surgical approach – depends on nature and extent of disease
- Palliative supportive periodontal care – patients who are not
comply with treatment, have poor oral hygiene, medically or
mentally compromised, functionally impaired.
XEROSTOMIA
Fluoride rinses and dentifrices
Reduced consumption of alcohol, tobacco, spicy and acidicfoods
Frequent water in take
Artificial salivary substitutes
Burning mouth
Salivary substitutes
Diphenhydramine, koalin, lidocaine mouth wash
Aging dental patients have particular oral and general health conditions that dentists should be familiar with detecting, consulting, and treating.
Medical diseases and conditions that occur more often with age may require modification to periodontal preventive tools as well as the planning and treatment phases of periodontal care.
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3. Savitt ED, Kent RL. Distribution of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis by subject age. J Periodontol. 1991; 62: 490-494.
4. Van der Velden U. Effect of age on the periodontium. J Clin Periodontol. 1984; 11: 281 -294.
5. Needleman I. Envelhecimento e o periodonto. In: Newman MG, Takei HH, Carranza FA. Periodontia clínica. 9.ed. Rio de Janeiro: Guanabara Koogan; 2004. p.51-5.
6. Abiko Y, Shimizu N, Yamaguchi M, Suzuki H, Takiguchi H. Effect of ageing on functional changes of periodontal tissue cells. Ann Periodontol. 1998; 3: 350-369.
7. Dumas M, Chaudagne C, Bont F, Meybeck A. In vitro biosynthesis of type I and III collagens human dermal fibroblasts from donors of increasing age. Mech AgeingDev. 1994; 73: 179-187.
8. Lee W, McCulloch CA. Deregulation of collagen phagocytosis in ageing human fibroblasts: effects of integrin expression and cell cycle. Exp Cell Res. 1997; 237: 383-393.
9. Locker D, Slade GD, Murray H. Epidemiology of periodontal disease among older adults: a review. Periodontol 2000. 1998; 16: 16-33.
10. Marsillac MWS, Mello HSA. Doença periodontal em idosos. In: Mello HSA. Odontogriatria. São Paulo: Santos; 2005. p.107-14.
11. Zenóbio EG, Toledo BEC, Zuza EP. Fisiologia, patologia e tratamento das doenças do periodonto do paciente geriátrico. In: Campostrini E. Odontogeriatria. Rio de Janeiro: Revinter; 2004. p.184-98.
12. Berglundh T. Clinical & structural characteristics of periodontal tissues in young & old dogs. J Clin Periodontol 18:616;1991.
13. Van der Velden u. Effect of age on periodontium. J Clin Periodontol 11:81;1984.
14. Roholl PJM, Blauw E, Zurcher C, Dormans J, Theuns HM. Evidence for a diminished maturation of pre-osteoblasts into osteoblast during ageing in rats: an ultrastructural analysis. J Bone Miner Res. 1994; 9: 355-366.
15. Selkoe DJ. Deciphering Alzheimer’s disease: the amyloid precursor protein yields new clues. Science 1990; 248: 1058-1060.
16. McCord JM. Free radicals and inflammation:protection of synovial fluid by superoxide dismutase. Science 1974; 185: 529-531.
17. McArthur WP. Effect of aging on immunocompetent and inflammatory cells . Periodontol2000, 1999 : 16-53.
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19. Williams RC, Barnett AH, Claffey N, Davis M, Gadsby R, Kellet M et al.The potential impact of periodontal disease on general health: a consensus view. Curr Med Res Opin. 2008; 24: 1635-43.
20. Novak MJ, Potter RM, Blodgett J, Ebersole JL. Periodontal disease in hispanic Americans with type 2 diabetes. J Periodontol. 2008; 79: 629-36.
21. Nishimura F, Takahashi K, Kurihara M, Takashiba S, Murayama Y. Periodontal disease as a complication of diabetes mellitus. Ann Periodontol.1998; 3: 20-9.
22. Khader YS, Dauod AS, El-Qaderi SS, Alkafajei A, Batayha WQ. Periodontalstatus of diabetics compared with non-diabetics: a meta-analysis. J Diabetes Complication. 2006; 20: 59-68.
23. Shlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type 2 diabetes mellitus and periodontal disease. JADA 1990;121(4):532-6.
24. Bahekar AA, Singh S, Saha S, Molnar J, Arora R. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: a meta-analysis. Am Heart J. 2007; 154: 830-7.
25. Linden GJ, McClean K, Young I, Evans A, Kee F. Persistently raised Creactive protein levels are associated with advanced periodontal disease.J Clin Periodontol. 2008; 35: 741-7.
26. Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000; 342: 836-43.